2010 September | Paramedicine 101

Furosemide and Drug Shortages 2

09/30/2010 by Rogue Medic Leave a Comment

Also posted over at Rogue Medic, which is now at EMS Blogs.

I will keep pointing out the problems with furosemide (Lasix) and the evidence against it. Let’s ignore the problems with giving furosemide to patients who actually have CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure). Can medics correctly identify CHF/ADHF?

The EHS ePCR database identified paramedic reports in which furosemide was administered. As furosemide only appears in the CHF/pulmonary edema protocol, paramedic differential diagnosis of this was assumed by furosemide administration. Data abstraction from the EHS ePCR and ED chart included the EP primary diagnosis, considered the gold standard. Other data points collected included: demographic information; EHS treatment administered; treatment administered in the ED; adverse events and patient disposition.^[1]

They do not describe their method of selecting the charts.

Was it completely random?

Was it sequential?

How did they select their sample?

There were three objectives of this study. The first was to determine agreement between paramedic administration of furosemide with EP diagnosis of CHF. The second was to examine differences in interventions administered by paramedics and in the ED by EP diagnosis of CHF. The third objective was to identify any adverse events that occurred during patient care.^[1]

How much agreement on CHF/ADHF diagnoses?

Click on charts to make them larger.

It should be noted that seven patients without an ED diagnosis of CHF received ED furosemide and 43 patients received ED nitro with only eight of those having a primary diagnosis of ACS. This data put the accuracy of the primary ED final diagnosis as a reference standard into question, as it appears CHF may have been in the differential diagnosis for many patients not ultimately diagnosed with CHF. Secondary diagnoses were not sought out and included. Therefore, paramedic accuracy reported in this study may be falsely low, if CHF was part of the EP secondary diagnoses. It should also be noted that there were two patients with a diagnosis of “shortness of breath not yet diagnosed.” It is possible that these patients did indeed have CHF, but were not diagnosed until a later time during hospital care. This needs to be considered when determining paramedic diagnostic accuracy.^[1]

OK. For some reason, the emergency physicians gave furosemide to 21% of the patients they diagnosed with something other than CHF/ADHF. That may be explained by the CHF/ADHF being a secondary diagnosis.

This is something that should have been included in the study. What was being treated and for what reason. From the way they describe their data, they had the actual ED physician chart, not just a diagnosis. This is something they should include in a follow-up study, especially with a larger sample size.

Since two of the patients had the diagnosis shortness of breath not yet diagnosed I will move them to the CHF/ADHF side of the graph. After all, most of the patients were diagnosed with CHF/ADHF.

That looks so much better.

On the other hand, there are problems with the way they conclude that some patients do not have CHF/ADHF. How much higher would things be if secondary diagnoses were included?

It should be noted that seven patients without an ED diagnosis of CHF received ED furosemide and 43 patients received ED nitro with only eight of those having a primary diagnosis of ACS. This data put the accuracy of the primary ED final diagnosis as a reference standard into question^[1]

What does NTG (NiTroGlycerine) have to do with ACS (Acute Coronary Syndrome), when examining CHF/ADHF treatment?

NTG is the most effective medication for hypertensive CHF/ADHF. Go listen to the EMCrit CHF/ADHF podcast if you doubt me. For those not hypertensive, this research certainly suggests that NTG should be studied.

NTG is not just for chest pain.

Data abstraction from the EHS ePCR and ED chart included the EP primary diagnosis, considered the gold standard.^[1]

Maybe. Maybe not. And don’t get me started on Gold Standards.

ED mortality was higher in patients with an alternate diagnosis than those diagnosed with CHF by the EP (2/60 vs. 6/34, p=0.017). As documented on ED charts, eight patients in this sample suffered adverse events other than death. These adverse events were: hypotension (n =3), heart rate problem (n =3), electrolyte imbalance (n =1), and respiratory effort decline (n = 1). All of the patients who suffered adverse events were diagnosed with CHF by the EP. Adverse events were not associated with the amount of nitroglycerine, morphine or furosemide administered.^[1]

Adverse events in the ED were documented as occurring as often as death in the ED. Almost all of the deaths were in the group not diagnosed with CHF/ADHF, but all of the adverse events occurred in the group diagnosed with CHF/ADHF.

Of the six patients with an alternate diagnosis who had an outcome of death, three were diagnosed with pneumonia. Eight adverse events other than death were identified in this sample. Interestingly, all these patients were correctly identified as having CHF, which contradicts previous research which has found adverse events were more likely in patients incorrectly treated for CHF by paramedics.^11,12 This indicates that furosemide should be administered with caution, even in cases where diagnosis of CHF is correct.^[1]

Where is the evidence that furosemide should be administered, even if the diagnosis of CHF/ADHF is correct?

What would we want to know?

Did the patients have peripheral edema when given furosemide by EMS. Even with peripheral edema, furosemide is far from the first line drug, but without peripheral edema, it is not going to do anything good.

These patients need the best treatment possible, not the most persistent hold out from the Dark Ages.

We have known that CHF/ADHF is not primarily a fluid overload problem since the 1980s.

Why is EMS still using furosemide?

Is there any problem with a shortage of furosemide?

Not at all, but this isn’t the study to prove it.

I hope the authors use what they learned from this to design a definitive study of the prehospital use of furosemide.

Updated 02-07-11 to correct the uselessness of the original charts I made for this post.

More details are in Corrections of Misleading Charts.

Footnotes:

^[1] Correlation of paramedic administration of furosemide with emergency physician diagnosis of congestive heart failure
Thomas Dobson, Jan Jensen, Saleema Karim, and Andrew Travers.
Journal of Emergency Primary Health Care
Vol.7, Issue 3, 2009
Free Full Text . . . . . . . Free Full Text PDF

Filed Under: Critical Judgment, Heresy, Research, Rogue Medic, Uncategorized

NAEMSP Dialog – Pain Management

09/27/2010 by Adam Thompson, EMT-P 2 Comments

Below is one of my replies within the NAEMSP Dialog Group.

My Take:

Pain management starts with stress reduction and visa versa. One
common modality that is often overlooked is the use of an ice/cold
pack. For musculosckeletal injuries, this is often my primary
treatment.

I believe that, in general, all [prehospital] healthcare providers,
including myself are poor providers of pain management. As mentioned
by the others here, this is all-to-often as a result of those whom
inappropriately seek pain management. Also, not trusting the
patient’s representation of the severity of pain. Both should have no
baring in the back of an ambulance.

Maybe the paramedicine curriculum has changed, but I don’t remember
the part of the text book that mentions drug addiction as a
contraindication to pain management. Dr Bledsoe?

Withdrawal symptoms may be worse than overdose symptoms right? Well
they are most definitely worse than the symptoms that will present
after a therapeutic level of pain relief is reached. The most common
symptom there is PAIN RELIEF.

Drug seeker = someone still in pain.

Not that every one deemed a drug seeker really is, but lets consider
the consequences of providing them with what they want. Many who fall
victim to opiod/opiate addiction do so because of an initial symptom
of pain. They found relief with the drugs, and found pain when they
stopped taking them. So when they present to EMS with a complaint of
pain, they probably have pain. Yes, it may be pain due to the falling
levels of narcotic within their body, but do you know that? More
importantly, do you care? They are in pain, and we can treat pain.
This is an extreme argument I know. The argument against this could
be a straw man built on the basis that this would lead to an EMS pain
relief dependancy, or contribution to the problem. Until us
paramedics are taught differently, shouldn’t we do what we are
taught? The complaint is real unless proven otherwise.

If we are in the practice of following the evidence, than we obviously
need to rethink the way we withhold pain management. And by
‘rethink’, I mean ‘omit’.

Consider the following:

If epinephrine was a schedule one narcotic that was commonly abused,
would you withhold it if an “epi-abuser” presented with anaphylaxis?
The drug abuser is often in more pain than the patient who has never
had an opiate in their system. We aren’t handing out prescriptions or
giving large doses, we are just getting them to the hospital.

This is just my point-of-view and I am aware of the holes. Nothing is
absolute and this is no exception.

Adam Thompson, EMT-P
Lee County EMS
EMS Educator – Edison State College
Paramedicine101.com
EMSresponder.com
Lee County, Florida

Filed Under: Clinical Discussion

A Prehospital Pain Management Discussion at the NAEMSP Site

09/21/2010 by Rogue Medic 1 Comment

Also posted over at Rogue Medic.

I would have also posted this at Research Blogging, but this discussion is not the kind of research blog post that they are looking for.

Well, what needs to be said about prehospital pain management?

Drug Seekers.

Fentanyl vs. Morphine.

Fractures dispatched BLS vs. ALS.

Standing orders vs. Mother-May-I?

Nitrous oxide, etomidate, ketamine, NSAIDs (Non-Steroidal Anti-Inflammatory Drugs), relaxation, ice, acupressure, et cetera. If it might be used by EMS for pain, it is fair game for the discussion.

Legal issues – when will the lawyers start going after medical directors/medical command physicians for withholding appropriate treatment/neglect/malpractice?

Pediatric Pain Management by EMS.

And more.

There is a discussion of Prehospital Pain Management on the NAEMSP (National Association of EMS Physicians) discussion site on Google Groups. NAEMSP Dialog. Anyone can read the discussions. They are there to be a kind of reference for people working in EMS. This is what some of the top doctors, administrators, educators, street providers, and even the occasional blogger have to say on a topic.

Here is a summary of the rules on participation:

Trying to facilitate a higher level of discourse on contemporary issues in EMS. Most of the list members are physicians, managers, and educators – along with street level EMTs and paramedics with an interest in academics and policy issues.

Everyone who wants to join the list has to provide their name and affiliation; all posts are reviewed by a moderator before being allowed to circulate; and all posts must be ‘signed’. There is some descriptive language about the Dialog on the home page of the Google Group (http://groups.google.com/group/naemsp-dialog).

Go read. If you want to comment, sign up, but don’t try to push the envelope on what you can get away with. The envelope has already been pushed.

Some familiar bloggers are also participating – Adam Thompson, EMT – P from Paramedicine 101, Tom Bouthillet from Prehospital 12 Lead ECG, Mark Glencorse from Medic999, and a couple of doctors from the EMS Garage – Dr. Bryan Bledsoe and Dr. Keith Wesley. Some of the other top medical directors in the country are participating as well.

Filed Under: Clinical Discussion, Critical Judgment, Heresy, Rogue Medic, Uncategorized

Differential Diagnosis Series – Abdominal Pain (Part 2)

09/15/2010 by 510medic 2 Comments

This post is the second of two detailing the construction of a differential diagnosis for abdominal pain. The post yesterday consisted of a review of the relevant history and physical exam for abdominal pain patients. This article is also posted at my site: 510medic.com

COMMON EMS DIAGNOSES
While many causes for abdominal pain require lab work and diagnostic studies in the hospital environment, there are some common or potentially life-threatening diagnoses that are considering “can’t miss” in the prehospital setting.

APPENDICITIS
Appendicitis, as the name might suggest, is inflammation of the appendix. Caused by blockage of the entrance of the appendix, the organ swells, eventually bursting and filling the abdominal cavity with infectious material. The result of an abdominal infection is peritonitis, another life threatening condition. Traditionally, there are several signs that have been taught to EMS responders to determine if a patient has a probable appendicitis: fever, rebound, guarding and tenderness over McBurney’s point. As it turns out, fever is neither sensitive (15-67%), nor highly specific (85%) for appendicitis (1). As a refresher, this sensitivity means that 15-67% of abdominal pain patients with no fever (a negative finding) will not have an appendicitis. Needless to say, this number does not inspire a lot of confidence in ruling out appendicitis. Conversely, 85% of patients with an appendicitis will have a fever (1). McBurney’s point (halfway along a line drawn from the umbilicus to the iliac crest) is no better, Tenderness over that point is present in only 50% of appendicitis patients. Lastly, rebound has a sensitivity of 61% and a specificity of 82% and guarding has a sensitivity of 46% and a specificity of 92% (1). So what this all means is that a patient with abdominal pain and all of the following symptoms: fever, pain over McBurney’s point, guarding and rebound tenderness likely has an appendicitis. What this also means is that a patient can have abdominal pain and none of the other symptoms and still have an appendicitis.

ECTOPIC PREGNANCY
An ectopic pregnancy occurs when an embryo implants somewhere other than the uterus. Most often, this implantation occurs in the fallopian tube and can cause a rupture as the pregnancy progresses. This obviously represents a significant threat to the life of the mother. As ruptured ectopic is the leading cause of pregnancy-related death during the first trimester (2), it is important to keep a high index of suspicion, since a patient may not yet know she is pregnant. To this end, any female patient of child-bearing age presenting with abdominal pain, syncope, hypotension or vaginal bleeding should be considered for a possible ruptured ectopic. Pain from a ruptured ectopic pregnancy will typically present in the right or left lower quadrant (depending on which side the pregnancy implanted) and may present with profound hypotension. Ultimately, clinical findings cannot effectively rule out ectopic pregnancy and an in-hospital ultrasound is needed (2).

PANCREATITIS
Pancreatitis is inflammation of the pancreas occurring in either chronic or acute forms. Chronic pancreatitis can result from alcohol and illicit drug abuse and, as such, is more often seen in the prehospital setting. Most of the actual diagnostic work for pancreatitis takes place in the in-hospital setting. Lab values are particularly helpful including pancreatic function tests and, of course, the ever-present abdominal CT (1). In the prehospital setting, most of the leg work goes towards history-taking. Patients with epigastric pain, often radiating to the back, with associated nausea and vomiting and a history of chronic alcohol abuse who have been ruled out for cardiac and respiratory causes should be considered for pancreatitis (1). Additionally, a history of pancreatitis diagnosis and a comparison of the presenting symptoms to the historical symptoms is helpful.

BOWEL OBSTRUCTION
As the name indicates, this condition occurs when something obstructs the passage of fecal matter through the bowels. This condition can result from chronic constipation, foreign object, or conditions like cancer or polyps. Over half of the cases of large bowel obstruction result from the presence of cancer (1). Patients generally present with episodes of increased pain during which bowel sounds are notably louder (even audible without a stethoscope). The patient may present with abdominal distention (89% specific), previous abdominal surgery (94% specific) and constipation (95% specific) (1). While these findings are fairly specific (positive findings rule in large bowel obstruction), they are relatively insensitive (a negative finding does not reliably rule out large bowel obstruction). Making up 80% of bowel obstruction cases, small bowel obstruction is most often caused by post-operative adhesions (70%) (1). For the purposes of the prehospital community, large and small bowel obstruction present with essentially the same findings in the history and exam. Field treatment of bowel obstruction includes fluid resuscitation and pain management.

MESENTERIC ISCHEMIA
The small intestine is supplied with blood and nutrients by the mesenteric artery. When this artery does not provide adequate circulation, ischemia of the small bowel can result. While it can be caused by hypotension from hemorrhage in trauma (resulting in the “golden hour” – but that’s another post), the disease process here results from a clot blocking blood flow. Other than abdominal pain, there are not many physical findings in EMS which can aid in a differential diagnosis of mesenteric ischemia. If advanced, ischemia may result in decreased bowel sounds. Often, patients will complain of pain much more severe than their physical finding would indicate (1). A thorough history will serve the practitioner in this diagnosis. Patients at high risk for clotting (history of atrial fibrillation, CHF, bed confinement, and recent surgical procedures) should be considered high risk for mesenteric ischemia (1). Since the presence of mesenteric ischemia can be so life threatening, rapid transport should be considered if this disease process is considered likely.

CHOLECYSTITIS
Hopefully by this point we’re all on board with “-itis” meaning inflammation. In this case we’re talking about the gall bladder and inflammation and pain specific to it. The inflammation in question generally results from a prolonged blockage of the common bile duct, often resulting from gall stones. The pain from cholecystitis is found in the right upper quadrant 54% of the time and in the epigastric region 34% of the time. The pain generally comes and goes and is often cramping in nature, radiating to the back, flank and chest (1). For this reason, it is important to determine where the pain started before radiating and also to perform a 12 lead ECG for abdominal pain patients.

ABDOMINAL AORTIC ANEURYSM
An aneurysm is an out-pouching from an artery caused by a weakening of the arterial wall (see my post about CVA for some images of a cerebral aneurysm; same idea, different location). In the abdomen, pain can be caused by an aneurysm of the abdominal aorta, a life-threatening condition requiring rapid assessment and treatment. It is important to note that ultimately, the physical exam cannot totally rule out AAA from consideration. One of the most important findings in the patient examination for ruling in AAA is orthostatic vital signs. Since the patient often will not have large quantities of emesis or diarrhea, dehydration is ruled out as a cause of abnormal vital signs. A history of GI bleed symptoms (or lack thereof) will rule in or out that diagnosis as well. The classic presentation of AAA is historical hypertension, presenting with constant, severe abdominal pain, pulsating mass in the abdomen and profoundly positive orthostatic vital signs. It is important to note, however, that for symptomatic AAA, a palpable mass is only present in 18% of patients (1). For a ruptured AAA, the treatment is surgical. Think of this as a trauma patient; the speed with which a patient can bleed out is staggering. In this case, C3 transport is obviously indicated.

CONCLUSION
Abdominal pain is a frequent call for many EMS responders. Given the breadth of possible causes, it is important for practitioners to keep a high index of suspicion for life-threatening causes. Performing a thorough physical exam and history on patients with abdominal pain (even chronic ones!) will help to ensure that “must catch” diagnoses are caught. Do your patients a favor and make sure that you give them the benefit of the doubt, particularly with a complaint as complex as abdominal pain.

CITATIONS

1 – Stern, Scott; Cifu, Adam; Altkorn, Diane. Symptom to Diagnosis: An Evidence-Based Guide. New York: Lange Medical Books, 2006.

2 – Lozeau, Anne-Marie; Potter, Beth. Diagnosis and Management of Ectopic Pregnancy. Am Fam Physician. 2005. 72(9): 1707-14.

Filed Under: Assessment, Clinical Discussion, Medical Emergencies

Differential Diagnosis Series – Abdominal Pain (Part 1)

09/14/2010 by 510medic 3 Comments

This post is the second in a series detailing the differential diagnosis process. The first article reviewed the basics of differential diagnosis and this and subsequent posts will look at the process for specific complaints which frequently present to EMS. This post is the first of two detailing the construction of a differential diagnosis for abdominal pain. This article is also posted at my site: 510medic.com

INTRODUCTION
You are dispatched to a private residence 30 minutes before the end of your shift for abdominal pain. What goes through your mind en route? Aside from the obvious frustrations of course. What symptoms do you think about on the way? What possible diagnoses do you consider? What concerns do have about the patient?

Abdominal pain represents one of our frequent calls in EMS. It is also one of the hardest complaints to diagnose. The abdomen houses many organs, any of which could cause pain, and abdominal pain can be a symptom of serious conditions including cardiac disease and pneumonia.

DIFFERENTIAL DIAGNOSIS REVIEW
As discussed in the first article in this series, differential diagnosis is the method of evaluating data from examination and assessment to construct causes for presenting complaints. An initial list is constructed based on the complaint or body system involved. This list is narrowed down by findings that move the index of suspicion to the point that you are comfortable either treating or discarding that cause. The usefulness of a test is quantified by specificity and sensitivity. A positive result in a highly specific test means it is likely a patient has a certain disease. A negative result in a highly sensitive test means it is likely that the patient does not have a certain disease. Tests and assessments continue until your index of suspicion crosses the threshold to treat or ignore and you move to the next potential cause.

CONSTRUCTING A DIFFERENTIAL FOR ABDOMINAL PAIN
In building a list of causes for abdominal pain, the provider considers three important aspects: the specifics of the pain, the patient’s history and the findings during the physical examination. When reviewing the patient’s pain, the PQRST mnemonic (P – Provoke/Palliate, Q – Quality, R – Radiation, S – Severity, T – Time) can help to ensure than nothing is missed. These findings, along with the location of the pain, can help construct a list of causes. For instance, upper abdominal, or epigastric pain can be caused by the organs in that area: the pancreas, gall bladder and stomach; though sometimes epigastric pain can result from a heart attack. Knowing which organs are where is important because, for instance, pain from an appendicitis is likely to occur in the right lower quadrant so choosing that as a differential diagnosis for left upper quadrant pain could be a dangerous mistake.

Abdominal Organ Locations - via Flickr

Along with information about the patient’s pain, you should take a detailed history from the patient. Knowledge of associated symptoms can aid in the construction of a differential diagnosis. Some historical findings include:

Nausea/Vomiting
Diarrhea
Constipation
Change in oral intake
Blood in the stool/urine
Fever/Chills

By asking these questions, you are able to know the time frame of the symptoms and the organs or body systems affected.

In addition to symptoms associated with abdominal pain, it is vital to ask about the remainder of their medical history. Particular attention is paid to respiratory symptoms and any cardiac history as abdominal pain may be a presenting symptom in both an acute myocardial infarction and pneumonia. Lastly, the patient’s sexual/reproductive/menstrual history should be noted and any alcohol or drug usage.

The next step in the diagnosis of abdominal pain is the physical exam beginning with vital signs. In addition to the standard set of vitals, consider checking for positive orthostatic changes (a drop in blood pressure and an increase in heart rate when moving from lying to sitting and sitting to standing). Positive orthostatic findings include a systolic blood pressure drop of 20 mmHg or a heart rate increase of 20 BPM. Care must be taken with patients on heart rate control medications (like Atenolol) because their heart rates cannot increase during times of shock.

Continuing the physical examination, the practitioner performs a cardiac and respiratory exam including 12 lead ECG, lung sounds and heart tones. Since life threatening conditions like acute MI and pneumonia can present as pain referred to the upper abdomen or epigastric region, it is important to rule out the presence of these conditions early in the construction of a diagnosis.

Finally, the physical exam proceeds to the actual hands on assessment. The patient is assessed through visual inspection of the abdomen, auscultation to check for the presence or absence of bowel sounds and palpation using first light pressure then deeper pressure. During the palpation phase, it is important to talk to the patient to distract him and to work towards the region where the complaint of pain exists.

CONCLUSION
Based upon specific findings during the history and physical examination, the practitioner should be able to determine the underlying cause of the patient’s complaint. In tomorrow’s post, we will present a review of some of the common causes of abdominal pain and which specific findings may indicate an underlying cause. Stay tuned!

Filed Under: Assessment, Clinical Discussion, Medical Emergencies

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract

09/07/2010 by Adam Thompson, EMT-P 1 Comment

I have moved Rogue Medic to EMS Blogs. Also posted over at Rogue Medic and at Research Blogging.

Go check out the rest of what is available at EMS Blogs and at Research Blogging.

Over at 510 Medic, there is an interesting abstract of a new article on treatment of tension pneumothorax. Frequency of Inadequate Needle Decompression in the Prehospital Setting.

CONCLUSIONS: In this study, 26% of patients who received needle thoracostomy in the prehospital setting for a suspected PTX appeared not to have had a PTX originally, nor had 1 induced by the needle thoracostomy. It may be prudent to evaluate such patients with bedside ultrasound instead of automatically converting all needle thoracostomies to tube thoracostomies.^[1]

I have not read the full text. ~~I do not have access to this journal. If anyone can send me the full text, I would like to address some of the details, rather than just speculate about them.~~ Late entry – I have received the article. Thank you to Jeff Williams and Jeremy Blanchard. I will write more about the full text later on.

510 Medic makes some important points and asks some good questions. Then 510 Medic asks –

So if we subscribe to the goal of “first do no harm” and those 15 patients didn’t have a pneumothorax induced by the procedure, is their discomfort worth proper treatment for the remaining 42 patients?^[2]

I think that there is a more important question.

Should we assume that the presence of a pneumothorax is an indication for needle decompression?

A pneumothorax is not the same as a tension pneumothorax. Even the definition of a tension pneumothorax is not easy to agree on. I tend to treat with opioids what many others would treat with needle decompression. I have not had any of these patients deteriorate, while in my care. They received chest tubes in the trauma center.

Should we assume that the presence of a pneumothorax is an indication for needle decompression?

57 patients with a prehospital diagnosis of tension pneumothorax. Yes, EMS does diagnose, but that is a discussion for elsewhere. Yes, these patients were diagnosed by EMS with tension pneumothorax, unless we are suspecting acupuncture, because what other prehospital indication is there for sticking a needle into a patient’s chest?

Out of 57 patients diagnosed with tension pneumothorax, only 42 patients had a pneumothorax.

How many patients had a tension pneumothorax at the time the needle was stuck into the chest wall?

How many of those patients would have been better off if treated with something other than a needle?

How many complications were there from the needle decompression?

Am I wrong to use italics to highlight the word decompression, since so many of the patients did not have anything to decompress?

We rush to perform procedures that we have little experience with. Isn’t this a situation likely to lead to misdiagnosis?

Isn’t the infrequent use of needle decompression for suspected tension pneumothorax likely to lead to operator error?

The actual occurrence of tension pneumothorax appears to be much less frequent than the prehospital diagnosis of tension pneumothorax. Isn’t that an indication of a failure to properly educate medics?

Footnotes:

^[1] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed - in process]

^[2] Frequency of Inadequate Needle Decompression in the Prehospital Setting
510 Medic
Article

Filed Under: Critical Judgment, Heresy, Research, Rogue Medic

Research: Prehospital Pain Management

09/06/2010 by Adam Thompson, EMT-P 1 Comment

Check this out…

I’m not sure why IV Fentanyl wasn’t compared to Morphine, but the study is interesting none-the-less.

Prehosp Emerg Care. 2010 Oct-Dec;14(4):439-47. [Pubmed]
Effectiveness of morphine, fentanyl, and methoxyflurane in the prehospital setting.

Middleton PM, Simpson PM, Sinclair G, Dobbins TA, Math B, Bendall JC.

Abstract

Abstract Objective. To compare the effectiveness of intravenous (IV) morphine, intranasal (IN) fentanyl, and inhaled methoxyflurane when administered by paramedics to patients with moderate to severe pain. Methods. We conducted a retrospective comparative study of adult patients with moderate to severe pain treated by paramedics from the Ambulance Service of New South Wales who received IV morphine, IN fentanyl, or inhaled methoxyflurane either alone or in combination between January 1, 2004, and November 30, 2006. We used multivariate logistic regression to analyze data extracted from a clinical database containing routinely entered information from patient health care records. The primary outcome measure was effective analgesia, defined as a reduction in pain severity of >/=30% of initial pain score using an 11-point verbal numeric rating scale (VNRS-11). Results. The study population comprised 52,046 patients aged between 16 and 100 years with VNRS-11 scores of >/=5. All analgesic agents were effective in the majority of patients (81.8%, 80.0%, and 59.1% for morphine, fentanyl, and methoxyflurane, respectively). There was very strong evidence that methoxyflurane was inferior to both morphine and fentanyl (p < 0.0001). There was strong evidence that morphine was more effective than fentanyl (p = 0.002). There was no evidence that combination analgesia was better than either fentanyl or morphine alone. Conclusion. Inhaled methoxyflurane, IN fentanyl, and IV morphine are all effective analgesic agents in the out-of-hospital setting. Morphine and fentanyl are significantly more effective analgesic agents than methoxyflurane. Morphine appears to be more effective than IN fentanyl; however, the benefit of IV morphine may be offset to some degree by the ability to administer IN fentanyl without the need for IV access.

Pain management is one of those things commonly under done by paramedics. I believe common reasons for this lack of treatment include laziness, apathy, and disbelief. Paramedics don’t want to do the added paperwork that goes with administering a controlled substance. They may not care too much about the pain that their patient is in, and are much more concerned about life-threatening conditions. Finally, the existence of drug seekers most-definitely decreases the amount of pain meds administered prehospitally. Whatever the reason, it isn’t a good one. If your patient complains of pain, it should be treated. An ice pack or positioning may be enough for some, while heavy doses of potent narcotics may be required for others. We have the tools, now lets use them.

I have added the Wong-Baker ‘faces’ pain scale here to remind you of how to judge your pediatric patient’s pain. The old one through ten severity scale is suffice for adults.

Filed Under: Pharmacology, Research

Learn It: Angioedema

09/05/2010 by Adam Thompson, EMT-P 5 Comments

Angioedema

Sometimes referred to as Quinke’s Edema, angioedema is that swelling we see that is most apparent around the mucosal areas of the face. Consider Hives as swelling on the surface of the skin, and angioedema as swelling beneath the skin.

The most common cause of this type of swelling without the presence of Hives is hypersensitivity to ACE inhibitors.

ACE = Angiotensin converting enzyme. This converts angiotensin one into angiotensin two.

ACE inhibitors block ACE.

Bradykinin is a peptide that has a role with all forms of angioedema. It is a potent vasodilator that increases permeability and allows the accumulation of fluid within the interstitial space.

ACE is one of the main ways that bradykinin is degraded. So when we inhibit the production of ACE, we are then inhibiting the degradation of bradykinin. We then have this run away peptide and subsequent swelling.

Many patients that suddenly present with severe angioedema have been taking ACE inhibitors, such as lisinopril, for a long period of time. They may have never had any issues before, but out of no where have this severe reaction. This type of reaction is most common in the African-American population, but may occur in anyone.

There are other types of angioedema, including the traditional allergic reaction. Those are more well known and prepared for.

Treatment

As you can see from the pictures above, swelling may be within the oropharynx. This can cause an airway obstruction, and aggressive airway management should be advocated.

This patients may be obtunded and snoring as you enter the scene. They have been confused for diabetics, or acute coronary syndrome patients due to their initial impression.

It is common for these patients to undergo cricothyrotomy due to complete glottic obstruction. Moving quickly is imperative to prevent severe hypoxia and cardiorespiratory arrest.

The usual drugs used for anaphylactic reactions are indicated.

- Epinephrine to reduce the vasodilation.

- Crticosteroids & antihistamines.

So the next time you run on a patient that is presenting with swelling in the absence of hives, think angioedema, and act fast!

Filed Under: Clinical Discussion, Education, Pharmacology, Toxicology